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    Followup Encounter Form

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    bhagirath
    Carla was seen at an assisted living facility for a follow-up visit. Her vital signs were stable. Her chief complaints included severe and persistent dementia, a moderate rash that was improving with medication, and moderate and recurrent failure to thrive. The plan was to continue her medications for dementia and rash, verify if she had been referred to dermatology, and have staff monitor her food intake. She was scheduled for a follow-up visit in four weeks.

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    Followup Encounter Form

    Uploaded by

    bhagirath
    35 views2 pages
    Carla was seen at an assisted living facility for a follow-up visit. Her vital signs were stable. Her chief complaints included severe and persistent dementia, a moderate rash that was improving with medication, and moderate and recurrent failure to thrive. The plan was to continue her medications for dementia and rash, verify if she had been referred to dermatology, and have staff monitor her food intake. She was scheduled for a follow-up visit in four weeks.

    Original Description:

    Jean

    Original Title

    R-60686-4488-0-0-imee-2017-10-25-13-40-31-0-0-0-0-0-00-04-16-sknation2 Jean Casey

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    Carla was seen at an assisted living facility for a follow-up visit. Her vital signs were stable. Her chief complaints included severe and persistent dementia, a moderate rash that was improving with medication, and moderate and recurrent failure to thrive. The plan was to continue her medications for dementia and rash, verify if she had been referred to dermatology, and have staff monitor her food intake. She was scheduled for a follow-up visit in four weeks.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    35 views2 pages

    Followup Encounter Form

    Uploaded by

    bhagirath
    Carla was seen at an assisted living facility for a follow-up visit. Her vital signs were stable. Her chief complaints included severe and persistent dementia, a moderate rash that was improving with medication, and moderate and recurrent failure to thrive. The plan was to continue her medications for dementia and rash, verify if she had been referred to dermatology, and have staff monitor her food intake. She was scheduled for a follow-up visit in four weeks.

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    of 2

    FOLLOWUP ENCOUNTER FORM

    Patient Name: Carla


    Account number: 2065
    D.O.S: 10/31/2017

    Patient was seen in assisted living facility. History was provided by staff and in charge of patient.

    Vital signs at 03:00 P.M, heart rate 76, respiration 16, blood pressure 122/62, oxygen saturation
    98%.

    Chief Complaint:
    1 Dementia .
    Pattern: Persistent.
    Status: Chronic.
    Severity: Severe.
    Course: Constant.
    Relieved by: Medication.
    Associated Features: Patient kept repeating himself. Initially refusing vital signs stating
    that was not enough information to make a diagnosis.
    2. Body rash.
    Pattern: Persistent
    Status: Controlled
    Severity: Moderate.
    Course: Constant.
    Relieved by: Medication
    Associated Features: Patient was wearing long pants and long jacket, refused to remove
    jacket for exam. Though no rash observed on his face and neck. Janitor stated
    Dermotology has not deemed him well. Rash has been improving with promethrine
    cream.
    3. Failure to thrive
    Pattern: Persistent.
    Symptom: active
    Severity: Moderate.
    Course: Recurrent.
    Relieved by: Medication.
    Associated feature: staff reports he is eating but his lunch and dinner.

    CHECK BOXES: Check I have reviewed the documented medical, surgical, family, social etc
    and then also select change added from the last visit, which was 10/03/2017.

    REVIEW OF SYSTEMS:
    General: Positive on able to conduct usual activities. Negative for comfortable. Positive for
    exercise intolerance. Postive on change of strength. Negative apperant distress
    HEENT: Decreased during positive.
    Dental difficulty negative. Sinus congestion negative. Dizziness negative. Hematology postive.
    Anemia postive

    Musculoskeletal: Positive for decreased range of motion. Positive for joint pain. Positive for
    muscle atropy. Positive for muscle weakness. Joint stiffness positive.
    In wheel chair.
    Skin: itching negative, rash positive.
    Cardiovascular: Negative for any chest pain. Elevated blood pressure negative. Fainting
    negative.
    Respiratory: Negative for shortness of breath.
    Neurological: Positive ataxia. Positive memory loss. Expressed confusion negative. Weakness
    negative. Dizziness negative. Tremor negative. Change weakness positive.
    GI: Negative for abdominal pain. Negative for constipation. Negative for diarrhea. Negative
    nausea. Negative vomiting. Positive Sclerosis..
    Psychiatric: negative for anxiety. Negative for depression. Confusion positive. Delusion
    negative. Hallucination negative. Agitation negative.
    Endocrine: appetite changes negative. Hypoglycemia negative

    Vital signs at 12:20 p.m. Heart rate 72, respirations 16, BP 144/72, and oxygen saturation 98%.

    PLAN:
    1. Mood - unable to fully asses carla.
    2. Dementia with mood disorder, continue with Sertraline.
    3. Body Rash - Continue promethrine cream. Please verify if dermatology refferel has been
    sent.
    4. Failure to thrive: Staff to monitor and P.O intake.

    MIPS: Most recent diastolic blood pressure 82, most recent systolic blood pressure less than 140,
    122
    Diastolic 10/31/2017
    Systolic 10/31/2017
    FOLLOW-UP: Follow-up in four weeks with Michelle.

    Please verify if the patient has been seen by dermatology and obtained records, labs 10/05/2017.

    Imee McGrath, ARNP

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